Shoulder Trauma Part 1- Bones
My name is Gavin Jennings. I am an Specialist Shoulder Surgeon based in Bath, UK.
This presentation gives an overview of trauma around the shoulder girdle.
The presentation is divided into 3 parts. Parts 2 and 3 will deal with tendons and ligaments respectively, whereas this first part will concern the bones
I would like firstly to briefly recap the relevant boney anatomy of the shoulder girdle.
The shoulder joint is formed by the ball (or head) of the humerus and the socket (or glenoid), which is part of the shoulder blade (or scapula). Other important parts of the scapula include the anterior protuberance called the coracoid and the flat acromion, which articulates with the collar bone (or clavicle) at the acromioclavicular joint. The humerus is composed of the head, the greater and lesser tuberosities, the neck and the shaft.
I will discuss fractures of the main bones as described above, starting with the most common i.e. clavicle fractures. (For a more in-depth review of clavicle fractures, please see the relevant separate presentation devoted to clavicle and ACJ injuries alone).
Clavicle fractures are very common representing 15% of all childhood fractures and 5% of all fractures in adults.
Many are treated non operatively such as those in younger children, and minimally displaced middle third fractures in all ages. Significantly displaced fractures, those with 2cm or more shortening, those in the outer third and open fractures are often treated operatively.
This is an example of a significantly displaced, comminuted ‘Z’ pattern fracture which we have fixed with a plate.
The next example is of a lateral clavicle fracture with unstable medial fragment (or Neer Type 2) which we have reduced and held with an artificial ligament.
Moving on to proximal humeral fractures now. These have long been described by the displacement of the constituent ‘parts’. The four parts are the two tuberosities, the head and the shaft.
The correct radiographs are needed for the initial assessment of these injuries and are often supplemented by a CT scan. The standard views are a true AP of the glenohumeral joint, a lateral scapular view and an axillary view. A routine axillary view is often very difficult to obtain in the trauma situation.
Instead we usually obtain a trauma axillary view such as A Velpeau view as shown
Proximal humeral fractures are often treated operatively, particularly in the younger patient, if the parts are displaced.
The options for operative treatment are fracture fixation versus hemiarthroplasty.
Operative treatment ideally involves fixation as the results of hemiarthrpolasty for fractures are not great.
Sometimes however, the fracture pattern may dictate that a hemiarthroplasty is the preferred option such as in fractures which split the head, or in displaced four part fractures with poor bone quality.
Here is an example of a displaced proximal humeral fracture
which we have fixed with a locking plate.
Here are the post-operative radiographs
A similar technique can be used for fractures also involving the shaft of the humerus as in this example.
Finally scapular fractures now. These are a bit of a mixed bag and are generally high energy injuries. They are rarely treated operatively, unless there is a displaced glenoid fracture, or if there are other injuries around the shoulder girdle constituting a so called ‘floating shoulder’ It is important to assess such patients for any underlying chest injury, of which there is a significant incidence.
To finish I would like to mention a rare but serious injury to the scapula area is the so called scapula-thoracic dissociation. This is a violent injury where the scapulothoracic articulation is disrupted usually in conjunction with disruption of the anterior part of the shoulder girdle. Often there is a devastating neurological and also vascular injury. In this example the scapular can be seen to be sitting laterally with a fracture of the acromion and proximal humerus.
The boney injuries were adequately fixed, as was the vascular injury.
Unfortunately the nerve root disruptions proximal to the plexus were not reparable.
Thank you for listening to Part 1 of the shoulder trauma overview.